Disseminated intravascular coagulation (DIC) Jørn Dalsgaard Nielsen Thrombosis Centre Gentofte Hospital Denmark

Disseminated intravascular coagulation

(DIC)

Jørn Dalsgaard NielsenThrombosis CentreGentofte Hospital

Denmark

Characteristics of DIC

Arterial thrombosis

Venous thrombosisDIC

Introduction

• Thrombotic microangiopathy (TMA) and disseminated intravascular coagulation (DIC) are disorders causing obstruction of the microvascular circulation

Trombotic

microangiopathy

Increased platelet aggregation

DIC

Increased fibrin formation

Thrombotic microangiopathy

Trombotic

microangiopathy


TTP HELLP HUS

TTP: Thrombotic Thrombocytopenic Purpura

HELLP: Haemolysis, Elevated Liver enzymes, Low Platelets

HUS: Haemolytic Uremic Syndrome

Type Symp. Etiology

TTP: CNS vW cleaving factor deficiency, cong/aquired

HELLP: Liver Pregnant women

HUS: Kidney +/- diarrhoea associated (E coli 0157)

Trombotic

microangiopathy


TTP HELLP HUS


Trombotic

microangiopathy


TTP HELLP HUS

Treatment: TTP HELLP HUS

• Eliminate the causal factor +

• Plasmapheresis (or FFP or cryosupernatant transfusion) +

• Corticosteroids (+) + (+)

• IV gamma globulin (+) (+)

• Rituximab + (+)

• Avoid platelet transfusions + + +


Criticalillness

DIC is a complication

Banal

Seriousillness

Causes of DIC

SepsisOther causes

The Vicious Cycle of Inflammation and

Coagulation

SepsisSepsisSepticSepticshockshock

SevereSeveresepsissepsis

The Vicious Cycle of Inflammation and

CoagulationInfectionInfection

InflammationInflammation

CoagulationCoagulation





Endothelial Endothelial DysfunctionDysfunction

IschemiaIschemiaOrgan FailureOrgan Failure

DeathDeath


Esmon. Esmon. Immunologist.Immunologist. 1998;6:84. 1998;6:84.

Progression of SEPSISProgression of SEPSIS

MonocytesEndothelial

cells

Cytokines

Endothelial cells

Tissue factor

Activation of coagulation Thrombin Fibrin

Platelets

Leuko-cytes

Non-adhesive surfaceA

dhesive surface

Accelerates coagulation

THE ”CLASSIC” COAGULATION SYSTEM

Surface contact Tissue factor

XII XIIa

XI XIa

IX IXa

X Xa X

II IIa

I Ia (fibrin)

Phospholipid, Ca++, VIII

Phospholipid, Ca++, V

VIIa VII

Ca++

APTT Prothrombin time

EXPRESSION OF TISSUE FACTOR

CONSTITUTIVE

e.g.:epithelial cellsglial cells

INDUCED

e.g.:monocytic cellsendothelial cells

PROHIBITED

e.g.:lymphocyteserythrocytes

IL-1TNF-C5a

Endothelial dam

age

Haemostatic

mechanisms

SYSTEMIC INFLAMMATION

TF

TF

TF

MonocyteActivation of monocytes

TF

TF

Cytokines

Intravascularclot formation

NORMAL HAEMOSTASIS

Activatedmonocyte

Causes of DIC (mechanisms)

• Extensive release of tissue factor• Increased formation of tissue factor• Abnormal activators of coagulation • Contact activation hypotension

Causes of DIC (Clinical conditions, I)

• Infections• Sepsis

– Gram negative (endotoxin)– Gram positive (polysaccharides, peptides)

• Viremias– Varicella– Hepatitis– Cytomegalovirus– HIV

Causes of DIC (Clinical conditions, II)

• Trauma• Crush injuries• Other trauma with tissue necrosis• Severe burns• Extensive surgery

• Obstetric complications• Amniotic fluid embolism• Placental abruption• (Pre)eclampsia• Dead fetus syndrome

Causes of DIC (Clinical conditions, III)

• Hemolysis• Hemolytic transfusion reactions• Massive transfusions• Malaria• Other severe hemolysis

• Malignant disorders• Metastatic malignancy• Tumors producing cancer procoagulant• Tumor with tissue necrosis

Causes of DIC (Clinical conditions, IV)

•Vascular abnormalities• Giant hemangioma• Heriditary teleangiectasis• Prosthetic devices

– Aortic balloon assist devices– Denver shunts

• Other conditions• Pancreatitis• Acute liver necrosis• Transplant rejection• Heat stroke

Progression of DIC

TimeOnset of DIC

Systemic fibrin formationSystemic inflammation

Multiple organ dysfunction

Systemic bleeding

Progression of DIC

TimeOnset of DIC

Systemic fibrin formationSystemic inflammation

Multiple organ dysfunction

High fibrinolytic activity

Abr

upt o

nset

of D

IC

Systemic bleeding

Low fibrinolytic

activity

Examples of hyperfibrinolytic DIC

• DIC in women with post-partum bleeding

• DIC in patients with promyelocytic

leukaemia

• Early after severe trauma

• Contact with Lonomia caterpillars

Thrombin- and stasis-induced release of tissue plasminogen activator

Fibrinolytic activity in patients with DIC

Abr

upt o

nset

of D

IC

Plasminogen Plasmin

Fibrin Fibrin degradation products

Plasminogenactivator

inhibitor-1

2-Plasmin inhibitor

During DIC FXII FXIIa PrekallikreinKallikrein

PC APC inhibits PAI-1

Hyper- and non-hyperfibrinolytic DIC

• Hyperfibrinolytic DIC– Main problem: Severe bleeding

• Non-hyperfibrinolytic DIC– Main problem: Microvascular occlusion

• DIC in septic patients is a

non-hyperfibrinolytic type of DIC

TF and LPS induced DIC

DIC was induced in rats by infusion of TF or LPS

TF LPS p

Platelets *109/l 204 177 ns

Fibrinogen mg/dl <50 <50 ns

TAT ng/ml 162 170 ns

D-dimer g/ml12,4 1,2 0,001

PAI U/ml 22 245 0,001

Glomerular fibrin 12% 73% 0,001

Asakura et al. Crit Care Med 2002; 30: 161-4

Clinical manifestations

of DIC

Symptoms of DIC

• Dysfunction of multiple organs– The pulmonary microembolism syndrome

• Acute: vascular and bronchial constriction• Late: ARDS

– Acute renal failure• Oliguria, increasing serum creatinine,

haematuria– Cerebral dysfunction

• Confusion, blurred consciousness, coma– Cutane haemorrhagic necroses– Failure of liver, endocrine glands etc.

Diagnostic criteria of DIC

MODS

SIRSDIC

IschaemiaIschaemia DestructionDestruction

ModificationModification(Amplification)(Amplification)

Local haemostatic response to an injury

Local immunological response to an injury

Circulating mediators

Circulating mediators

SIRS+DIC = hyperproteolysisSIRS+DIC = hyperproteolysis


FibrinolysisFibrinolysis

ComplementComplementKininesKininesCytokinesCytokines

BLOOD TESTS WHEN DIC IS SUSPECTED

Simple screening

Extended screening

Supplementary tests

Platelet count

Activated partial thromboplastin time (APTT)

Prothrombin time (PT)

Fibrin D-dimer fragment

Fibrinogen

Antithrombin

Further evidence for activation of coagulation

and fibrinolysis

Activation of coagulation

Prothrombin

THROMBIN

Antithrombin

Thrombin-Antithrombin

complex(TAT)

Fibrinogen

PlasminFibrin

FXIII FXIIIa

D fragmentsE fragments

D dimerE fragments

Fragment 1+2

Cross-linkedfibrin

Fibrino-peptideA + B

Soluble fibrin monomer as predictor for DIC in neonatal sepsis

• Healthy neonates: 24,5 ± 6,09 mg/l• Sepsis, no DIC: 33,7 ± 11,9 mg/l• Sepsis + DIC*: 73,2 ± 31,6 mg/l

Critical level: 48,5 mg/l

Sensitivity: 100%

Specificity: 93%

Overall accuracy: 97,5%Selim et al. Haematologica 2005;90:419-20

*ISTH DIC score 5

SCHISTOCYTES

THROMBUSFIBRIN

Longitudinally cut blood vessel

Definition of disseminated

intravascular coagulation

ISTH´s Scientific Subcommittee on DIC, July 2001

DIC is an acquired syndrome characterized by the intravascular activation of coagulation with loss of localization arising from different causes. It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction

Scoring system for overt DIC

• Platelet count– (>100=0, <100=1,

<50=2) ..............................• Soluble fibrin/D-dimer

– (normal=0, =2, =3) .............................• Prolongation of PT

– (<3s=0, 3-6s=1, >6s=2) ................................• Fibrinogen

– (>1g/l=0, <1g/l=1) ..........................................

• Calculate sum ........................................


YES NO

stopcontinue

• Underlying disorder known to be associated with overt DIC


• Platelet count– (>100=0, <100=1,



– (<3s=0, 3-6s=1, >6s=2) ................................• Fibrinogen

– (>1g/l=0, <1g/l=1) ..........................................

• Calculate sum ........................................


YES NO

stopcontinue


Polytrauma

85 1

8 3

+3 1

2,2 0

5

- Example -


• If the calculated score is 5: compatible with

overt DIC repeat scoring daily

– <5: suggestive (not affirmative) for non-overt DIC repeat next 1-2 days.


Scoring system for non-overt DIC• Presence of underlying disorder

– (no=0, yes=2) .......................................................... • Platelet count + changes

– (100=0, <100=1) + (=-1, stable=0, =1) .......• Sol.fibrin/D-dimer + changes

– (normal=0, =1) + (=-1, stable=0, =1) ........• Prolongation of PT + changes

– (3s=0, >3s=1) + (=-1, stable=0, =1) ...........• Antithrombin

– (normal=-1, low=1) .................................................• Protein C

– (normal=-1, low=1) .................................................• TAT complexes

– (normal=-1, high=1) .................................................

• Calculate sum ................................................


Validation of the ISTH scoring system for overt DIC

Distribution of DIC scores in 217 patients in intensive care unit

Bakhtiari et al. Crit Care Med 2004; 32:2416 –2421

Validation of the ISTH scoring system for overt DIC

Bakhtiari et al. Crit Care Med 2004; 32:2416 –2421

Validation of the ISTH scoring system for non-overt DIC

Non-overt DIC scores in 490 patients in intensive care unit

Toh & Downey. Blood Coagul Fibrinolysis 2005;16:69–74

Survivors

Deaths




• The mortality rate for non-overt DIC was – 29% (105 of 360) for scores below 5 – 78% (70 of 90) for scores of 5 or above

• The mortality rate for overt DIC was also 78% (38 of 49).

• The non-overt DIC scoring template is workable and has prognostic relevance.

• A score of 5 and greater is recommended as diagnostic of non-overt DIC.



• Platelet count– (>100=0, <100=1,



– (<3s=0, 3-6s=1, >6s=2) ................................• Fibrinogen

– (>1g/l=0, <1g/l=1) ..........................................

• Calculate sum ........................................


YES NO

stopcontinue


A low cutoff of 1 mg/l was used by:

1.Dempfle et al. Thromb Haemost 2004; 91: 812–82.Toh et al. Blood Coagul Fibrinolysis 2005; 16: 69-743.Angstwurm et al. Crit Care Med 2006; 34: 314–20

D-dimer- low cutoff -

Interassay variation of

D-dimer

D-dimer was determined in 39 plasma samples with 23 D-dimer assays

Dempfle et al. Thromb Haemost 2001; 85: 671–8

D-dimer tests giving comparable results

BioMérieux Vidas D-dimer

BioMérieux MDA D-dimer

Suggested cutoffs:

Low: 1 mg/l

High: 4 mg/l

Roche Cardiac D-dimer

Roche Tinaquant

Stago Liatest D-Di

Low HighWada et al. (2003) Dia-Iatron, LPIA-FDP 10 40 n.d./532 n.d./752 -Dhainaut et al. (2004) Stago, Liatest D-Di 0.4 4.0 166/454 = 37% 273/1114 = 25% 1.5Bakhtiari et al. (2004) BioMérieux, Vidas D-dimer 0.4 4.0 33/74 = 45% 36/143 = 25% 1.8

Dempfle et al. (2004)

BioMérieux, MDA D-dimerRoche, Tinaquant D-dimerIatro, SF

1.00.92.6

3.33.15.0

11/31 = 36%11/28 = 39%16/32 = 50%

47/301 = 16%47/304 = 16%42/300 = 14%

2.32.43.1

Toh et al. (2005) BioMérieux, MDA D-dimer 1.0 4.0 38/49 = 78% 105/360 = 29% 2.7

Sivula et al. (2005) Roche, Tinaquant D-dimer 2.0 8.0 38/95 = 40% 65/399 = 16% 2.5

Kienast et al. (2006) n.d. 0.4 4.0 12/42 = 29% 74/334 = 22% 1.3Angstwurm et al. (2006) BioMérieux, MDA D-dimer 1.0 5.0 15/28 = 54% 41/205 = 20% 2.7

Cauchie et al. (2006)

Stago, Liatest D-DiStago, FS testStago, FDP Plasma

n.d.n.d.20.0

n.d.n.d.40.0 18/32 = 56% 30/116 = 26% 2.2

Voves et al. (2006)Stago, Asserachrom D-DimerRoche, Enzymune-Test FM

0.92.6

3.15.0

6/10 = 60%7/12 = 58%

7/30 = 23%6/28 = 21%

2.62.8

Assay DIC No DICStudy Ratio

28-day MortalityFibrin-related markerCut-off (ug/ml)

Cut-off levels of fibrin related markers

Cut-off levels of D-dimerInfluence of low cut-off level of D-dimer on mortality

y = 0,7877Ln(x) + 2,3628

R2 = 0,7239

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

0,0 0,5 1,0 1,5 2,0 2,5

Cut-off level (mg/l)

Mo

rtal

ity

rati

o (

DIC

/No

DIC

)

The ATryn Study

Clinical Study Protocol

Exploratory efficacy and safety, pharmacokinetics and dosefinding study of recombinant human antithrombin in patients with disseminated intravascular coagulation associated with severe sepsis

Calculation of overt DIC score

Calculation of non-overt DIC

score

<

Treatment of DIC

PAR-1 NFB

T

TM

PC EPCR

TM

PC EPCR

TM

PC EPCR

TM

PC EPCRA

A

A

A

A

A

A

A

hrombin-signalingEndothelial cell

From normal haemostasis to sepsis

PAR-1 NFB

T

T

TM

PC

TM

PC

A

A

A

A

hrombin-signaling in sepsisEndothelial cell

T

T

T

A

T

T

T

T

T

T

T

CytokinesAdhesionmolecules

PAR-1 NFB

EPCR

EPCR

EPCR

EPCR

T

T

T

T

T

T

T

PAR-1 NFB

T

T

TM

PC

TM

PC

A

A

A

A


T

T

T

A


PAR-1 NFB

EPCR

EPCR

EPCR

EPCR

A

A

A T

T

T

T

T

T

T

Heparin

Elastase

T

T

T

T

T

T

Pulletz et al. Crit Care Med 2000; 28: 2881-6. Jordan et al. Am J Med 1989; 87 Suppl 3B: 1989

Treatment with heparin

PAR-1 NFB

T

T

TM

PC

TM

PC

A

A

A

A


T

T

T

A


PAR-1 NFB

EPCR

EPCR

EPCR

EPCR

A

A

A T

T

T

T

T

T

T

Heparin

Elastase

T

T

T

T

T

T

A

A

A

A

A

TT

TT

TT

Treatment with heparin and antithrombin

PAR-1 NFB

T

T

TM

PC

TM

PC

A

A

A

A


T

T

A

PAR-1

EPCR

EPCR

EPCRA

A

A T

T

T

T

T

T

T

Heparin

Elastase

T

T

T

T

T

T

A

A

A

A

A

TT

TT

TT

APC

APC

EPCR

T

Treatment with activated protein C +/- heparin

Role of heparin in sepsis

Echtenacher et al.

Infect Immun 2001; 69: 3550-5

Heparin treatment after cecum ligation and puncture increases mortality in rats (13% 75%, p < 0.015).

CLP+PBS

CLP+heparin

Heparin treatment after cecum ligation and puncture

The role of heparin in sepsis

Schiffer et al. Crit Care Med 2002; 30:2689 –2699

A DIC model:

22 sheeps had intravenous infusion of E. coli endotoxin


Cornet et al. Thromb Haemost 2007; 98: 579–586

A meta-analysis of animal studies


Cornet et al. Thromb Haemost 2007; 98: 579–586

LPS studies

LPS studies

N=2x5E. Coli antiserum

Dunn et al. 1983

Two studies showing negative effect of heparin were not included in the meta-analysis:

Corrigan et al. J Infect Dis 1975;131: 139–143. Echtenacher et al. Infect Immun 2001; 69: 3550-5

Role of heparin in sepsis

• Heparin seems to have:

– a beneficial effect in animal models where DIC is induced by endotoxin – probably due to the anti-inflammatory effect of binding and neutralisation of TNF

– a harmful effect when given to septic animals containing living bacteria.

Severe sepsis inducessystemic capillary leak

Sepsis-induced capillary leak syndrome

Decreased plasma activity of AT and PC in septic patients with DICAsakura et al. Eur J Haematol 2001; 67: 170-5

• Among 139 septic patients the 68 patients with DIC had significantly higher levels of TAT and lower levels of AT and PC than the 71 patients without DIC (p<0.001 for all variables) but no significant correlation was observed between plasma levels of TAT and AT or between plasma levels of TAT and PC.

• When the patients were classified into three groups according to the albumin level, no significant differences in AT activity or PC activity were observed between the patients with and without DIC.

Decreased plasma activity of AT and PC in septic patients with DICAsakura et al. Eur J Haematol 2001; 67: 170-5

The results suggest that the reduced activity of AT and PC is not due to consumption coagulopathy but rather to capillary leak, degradation by elastase, and/or reduced synthesis.

Dual-chamber system to analyze endothelial cell layer permeability

Endothelial cell layer

Polycarbonate membrane of 3µm pore size

Evans blue-labelled bovine serum albumin

Upper 500 µl chamber for addition of test material

Lower 1500 µl chamber for collection of media to be analyzed for Evans blue labelled bovine serum albumin (OD at 650 nm)

Feistritzer & Riewald. Blood 2005; 105: 3178-84

Endothelial barrier protection by activated protein C through PAR1-dependent

sphingosine 1–phosphate receptor-1 crossactivation

Feistritzer et al. Blood. 2005;105:3178-84

PAR1-dependent signaling by the interdependent procoagulant and anticoagulant proteases thrombin and APC can have opposite effects on endothelial barrier integrity. Barrier protection by APC or low concentrations of thrombin is mediated by sphingosine kinase-1 activity and crossactivation of S1P1 signaling.

APC reduces the mortality of LPS-induced endotoxemia in mice

APC

Saline

Kerschen et al. J Exp Med. 2007;204:2439-48


APC

Saline

EPCR / mice

- No effect in EPCR / mice -



APC

Saline

PAR1 -/- mice

- Reduced effect in PAR1 -/- mice -



5A-APC 2, 10 g

Saline

- and so does 5A-APC -5A-APC: A recombinant APC variant with normal signaling but <10% anticoagulant activity


Sepsis and DIC

• Septic patients may develope DIC as a result of activation of Toll-like receptors (TLRs) on monocytes, neutrophils and endothelial cells by microbial products like lipopolysaccharides, peptidoglycan, and lipoteichoic acid.

Zhang & Ghosh. J Clin Invest 2001; 107: 13-19

Henneke & Golenbock. Crit Care Med 2002; 30 Suppl: 207-13

TLR-mediated activation of

NFB

Zhang & Ghosh.

J Clin Invest 2001; 107: 13-19

Role of NFB in sepsis

Böhrer et al. J Clin Invest 1997; 100: 972-85

NFB in nuclear extracts from peripheral blood mononuclear cells is comparable to the APACHE-II score as a predictor of outcome in septic patients.

APC inhibits activation of NFB

Esmon CT. J Autoimmun 2000; 15 113-6:

• Activated protein C reduces nuclear translocation of NFB resulting in reduction of cytokine synthetic rates.

Antiinflammatory effects of APC

• APC blocks cytokine elaboration by mononuclear cellsGrey et al, J Immunol 1994;153:3664 –68

• Endothelial Protein C ReceptorFukudome & Esmon, J Biol Chem 1994;269:26486-91

• Mononuclear Phagocyte Protein C ReceptorHancock et al, Transplantation 1995;60:1525-32

Anti-inflammatory effects of AT

• Binding to endothelium stimulates prostanoid release– Yamauchi et al. BBRC 1989– Horie et al. Thromb Res 1990

• Increased prostacyclin levels in animal models – Uchiba et al. Thromb Res 1995 – Uchiba et al. Am J Physiol 1996

• Inhibition of endotoxin-induced cytokine synthesis, platelet aggregation, leukocyte differentiation and vascular permeability by prostacyclin – Uchiba et al. Thromb Res 1996

• Reduction of ischemia-reperfusion injury– Ostrovsky et al. Circulation 1997– Harada et al. Blood 1999

Anti-inflammatory effects of AT

• Inhibition of IL-6 and tissue factor release from endothelial cells and monocytes– Souter et al. Crit Care med 2001

• Inhibition of endothelial cell proliferation– Larson et al. J Biol Chem 2001

• ICAM-1-dependent inhibition of adhesion of neutrophils to endothelial cells– Kaneider et al. Ann Hematol 2003

• Inhibition of NFB activation in endothelial cells and monocytes– Mansell et al. FEBS Lett 2001 – Oelschlager et al Blood 2002

• Effect on endothelial-leukocyte interactions in endotoxemia exerted predominantly via the endothelium– Mizutani et al. Blood 2003

AT inhibits LPS-induced activation of NFB

Mansell et al. FEBS Letters 2001; 508: 313-7:

• LPS-induced, TLR4-mediated activation of NFB in human mononuclear cells was inhibited dose-dependently by AT.

• Modified AT without serpin activity had no effect.

• The effect was not increased by addition of heparin.

AT inhibits LPS-induced TF and IL-6 production by mononuclear cells, endothelial cells, and whole blood

• TF and IL-6 were determined after stimulation of whole blood, HUVEC, and MNC with LPS for 4-6 hours.

• Production of TF and IL-6 was reduced in the presence of varying concentrations of AT.

Souter et al. Crit Care Med 2001; 29: 134-9

� IL-6

TF

AT prevents LPS-induced pulmonary vascular injury

Uchiba & Okajima. Semin Thromb Haemost 1997; 23:583-90:• Intravenous administration of AT (250 U/Kg) to rats

prevented LPS-induced accumulation of leukocytes and increases in pulmonary vascular permeability.

• Trp49-modified AT, which lacks affinity for heparin, had no effect.

• AT had no effect in animals pretreated with indomethacin, suggesting that the protective effect was a result of endothelial release of prostacyclin.

• Inhibition of thrombin formation by inactive FXa did not prevent pulmonary vascular injury

Prevention of vascular leakage during sublethal porcine sepsis by antithrombin

Dickneite, G & Kroez, M

• Sepsis was induced in 18 pigs by a 3 hours infusion of LPS 0,25 g/kg/h.

• 90 minutes after start of LPS infusion the animals were randomised to:– AT 120 IU/kg iv bolus + 5 IU/kg/h iv infusion

– AT 250 IU/kg iv bolus + 10 IU/kg/h iv infusion

– Placebo (HSA)

Presented at the 13th Annual Congress of ESICM in Rome, 1-4 October 2000

Prevention of vascular leakage during sublethal porcine sepsis by antithrombin

Dickneite, G & Kroez, M

• The broadening and dispersal of interlobular connective tissue was decreased significantly and dose-dependently by AT.

• Also the periportal edematisation and accumulation of leukocytes could be reduced.

Presented at the 13th Annual Congress of ESICM in Rome, 1-4 October 2000

Conclusion:

Effect of AT on DIC in man- the first randomised study -

• 51 patients with DIC were randomised to substitution with– AT infusion, target: 100%– Heparin infusion, 3000 IU as bolus + 300 IU/h– AT + reduced dose of heparin (1000 IU + 100 IU/h)

• Conclusion:– AT reduced duration of DIC– Concomitant heparin caused:

• Acccelerated reduction of platelet count

• Increased consumption of AT

• Increased need of blood transfusion

Blauhut et al. Thromb Res 1985; 39: 81-9:

Randomised trials on the use of AT in patients with sepsis or evidence of DIC

Study Patients Treatment ControlBlauhut (1985) 51 AT(+Hep) HepVinazzer (1989) 133 AT HepInthorn (1993) 40 AT+Hep HepFourrier (1995) 32 AT PlaceboSchuster (1995) 42 AT+Hep HepEisele (1998) 42 AT PlaceboBaudo*(1998) 56 AT Placebo*Subgroup analysis


0,0 1,0 2,0

0,37 (0,15-0,88)

0,43 (0,20-0,92)

0,63 (0,28-1,39)

AT vs. Hep (N = 133)

AT vs. Placebo (N = 130)

AT+Hep vs. Hep (N = 150)

Mortality odds ratio

AT reduces mortality significantly when used alone but not when accompanied by heparin treatment

Randomised trials on AT replacement in intensive care management of patients

with an antithrombin activity below 70%

0,0 1,0 2,0 3,0 4,0

Harper (1991)

Albert (1992)

Diaz-Cremadez (1994)

Baudo (1998)

Waydhas (1998)

Total

Odds ratio

0,85 (0,51-1,73)

Mortality

KyberSept Study KyberSept Study

A phase 3 trial of antithrombin versus placebo in patients with severe sepsis or septic shock.

The trial was powered to detect a 15% reduction of an expected placebo 28-day mortality of 45%.

2339 patients were randomised. In the treatment group the mean increase in plasma antithrombin at 24 hours of inclusion was 130%.

Mortality was lower than expected and almost identical in the two groups (Antithrombin: 38,9% and placebo: 38,7%).

Warren et al. JAMA 2001; 286: 1869-78

KyberSept StudyKyberSept Study

A shortcoming of the study was that use of unfractionated or LMW heparin 10.000 IU was allowed without randomisation.

Less than a quarter of the patients in the study had no heparin.

Heparin increased the risk of poor outcome and adverse bleeding.

Warren et al. JAMA 2001; 286: 1869-78

KyberSept StudyKyberSept Study

Warren et al. JAMA 2001; 286: 1869-78

KyberSept: No Hep. N = 698

Placebo 43,6%Antithrombin 37,8%

Difference: 5,8%

p = 0,08

28-day mortality:


0,0 1,0 2,0

0,37 (0,15-0,88)

0,72 (0,55-0,96)

1,09 (0,89-1,32)

AT vs. Hep (N = 133)

AT vs. Placebo (N = 828)

AT+Hep vs. Hep (N = 1766)

Mortality odds ratio

AT reduces mortality significantly when used alone but not when accompanied by heparin treatment

KyberSept results included:

Effects of activated protein C

• inhibits leukocyte-endothelial cell interaction

• inhibits thrombin formation

• increases fibrinolytic activity

*Bernard GR et al. N Engl J Med 2001; 344: 699-709

Protein S

FVIIIa

FVa

Endothelial cell

Activation of protein C

ThrombomodulinProtein C

Thrombomodulin

Activatedprotein C

ThrombinEPCR

PAI-1 TAFI

Protein C in septic patients

• The plasma concentration of PC is reduced in septic patients due to– Capillary leak

– Degradation by elastase

– Decreased synthesis

– Increased consumption during DIC

• Activation of PC is compromised in septic patients because the endothelial expression of thrombomodulin and endothelial protein C receptor is suppressed

The PROWESS Study

Protein C Worldwide Evaluation in Sepsis

• Clinical controlled phase III multicenter

double-

blind placebo-controlled trial in severe

sepsis

Bernard GR et al. N Engl J Med 2001; 344: 699-709

PROWESS Study DescriptionPROWESS Study Description• Design

– Randomized, double-blind, placebo-controlled trial– 11 countries at 164 sites

• Population - Severe Sepsis– Presence of a known or suspected infection– Evidence of a systemic response to the infection (3 SIRS

criteria)– At least one sepsis-associated organ dysfunction of no greater

than 24 hours duration

• Treatment Arms– 1:1 randomization to Drotrecogin Alfa (activated) 24

µg/kg/hr or placebo for 96 hours

Data from the PROWESS TrialData from the PROWESS Trial

PROWESS Study DesignPROWESS Study DesignInfection with organ failureInfection with organ failure

Start of study drugStart of study drug infusion infusion

48 Hours Maximum - Consent - Start Drug

End of 96 hour infusion of study drugEnd of 96 hour infusion of study drug

Assessment of 28-dayAssessment of 28-dayall-cause mortalityall-cause mortality

Alive or Dead?Alive or Dead?

Routine Patient Care

Data from the PROWESS TrialData from the PROWESS Trial

ResultsResults Drotrecogin Alfa (activated) in patients with

severe sepsis:– Acceptable safety profile– Significantly reduces mortality

• 6.1% absolute, 19.4% relative risk reduction

• Lower mortality observed across most subgroups

Number needed to treat to save one additional life equals 16

Treatment of sepsis and DIC• Probably the primary goal of DIC treatment should

not be inhibition of coagulation but protection of endothelial cells from being activated to produce inflammatory cytokines and adhesion molecules.

*Okajima et al. Am J Hematol 1991; 36: 265-71

• Increased leukocyte-endothelial cell interaction may be the key mechanism in the development of organ dysfunction.

• Neutropenic patients are unlikely to develope septic ARDS*.

Treatment of sepsis and DIC• Activated protein C (APC) has in addition to its

anticoagulant effect been shown to inhibit leukocyte-endothelial cell interaction

• In the PROWESS trial (N = 1690) 28-days mortality was 6.1% lower in the APC group than in the control group (p < 0.01)*

• AT has EC protective properties when heparin is avoided.

• In the non-heparin groups of the KyberSept trial (N = 698) 28-days mortality was 5.8% lower in the AT group than in the control group (n.s.)**

*Bernard GR et al. N Engl J Med 2001; 344: 699-709

**Warren et al. JAMA 2001; 286: 1869-78

AT

Treatment of sepsis and DIC

• Natural anticoagulant

• Present on EC surface

• EC protective properties:– Inhibits activation of NFB

– Reduces effects of LPS

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aPC

AT

Treatment of sepsis and DIC





• Displaced from EC surface by heparin

• Reduction of mortality in patients with sepsis/DIC not proven in phase III trial





• Not displaced from EC surface by heparin

• Reduction of mortality in patients with sepsis/DIC proven in phase III trial

aPC

The face of sepsis

DIC

Systemicinflam-mation

Documents

Disseminated intravascular coagulation (DIC) Jørn Dalsgaard Nielsen Thrombosis Centre Gentofte Hospital Denmark